Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with significant medical and cognitive needs. One resident, admitted with diagnoses including seizures, Parkinson's Disease, HIV, weakness, and anxiety disorder, was observed asleep in her wheelchair with the call light placed on the bed out of her reach. The resident's records indicated a lack of coordination and a need for safety precautions, and a nurse had previously instructed her to use the call light for assistance. A certified nursing assistant confirmed during observation that the call light should have been within the resident's reach and repositioned it accordingly. Another resident, with a history of end stage renal disease, falls, diabetes, muscle wasting, encephalopathy, and dementia, was found sleeping in bed with the call light dangling off the bed and not within reach. This resident was noted to have highly impaired vision and was always incontinent. Staff interviews revealed that the call light could have been pinned to the resident's gown or pillow to make it accessible, and the Director of Nursing acknowledged that the call light should have been within reach. The facility's policy required that call lights be easily accessible to residents in bed or confined to a chair, and that residents unable to use the call light be checked frequently.